In the most malarious town on earth, I find Dr. Matthew Emer at his desk behind two sets of fly screens and under a ceiling fan. I introduce myself and tell Emer I am reporting on a campaign to wipe malaria off the planet. If I want to know why that is important and how hard it might be, I say, it seems a good idea to see how bad it can get and I've read that in Apac, a district of 515,000 people in northern Uganda, the average person is bitten four times a day by malaria-infected mosquitoes. Emer nods. There are other, more telling statistics, he says, like how in the worst weeks, his handful of staff members may treat 5,000 people. Or how from 2007 to '08, those treated included 70% of all children in Apac and nearly a third of the area's total population.
Emer also wants me to understand that contracting malaria is often just the beginning of one's troubles. Malaria might kill you. But if it doesn't, it may be the start of an endless cycle of illness and poverty. "Because kids get malaria, there is a lot of absence from school," he says. "So our kids don't do well. So they don't get good jobs, and they don't earn money. Then they have children, who also get sick, and the parents have to spend their little money on them instead of spending it on schools or other things and they have to stay home to look after them, so they lose more money. Malaria keeps us poor."
And as malaria breeds poverty, poverty breeds more malaria. "Say every house has five children and each child has five to 10 episodes of malaria a year," says Emer. "And Coartem [the most effective antimalarial drug] costs $8 to $10. That's up to $500 a year for someone who earns $1 a day or less." Emer watches me jot down the figures on my notepad.
"That doesn't add up," I say finally.
"It doesn't add up," repeats Emer.
"What happens to the children whose parents can't afford Coartem?" I ask.
"They die," replies Emer.
The need for foreign aid is never clearer than in a place where $500 can keep a family alive for a year. But Apac is also an example of how good intentions are no guarantee of good aid. On that first visit to Apac, in August 2009, I found two foreign aid programs, but neither concerned malaria, and one was even a wetland- preservation scheme that barred residents from draining the swamps that surrounded the town the very waters where mosquitoes could lay eggs.
Today aid donors and recipients are increasingly asking, Does aid work? After half a century during which benefactors gave billions of dollars to Africa and Asia, they are finding the answer is often no. There are as many reasons for aid's failure as there are bad aid projects in the world. But one aspect of modern aid that donors are particularly uneasy about is the way it feels unnervingly like a giant business. Global aid is worth about $120 billion a year, according to the Organisation for Economic Co-operation and Development, about the same as the combined annual output of the 20 poorest countries in Africa. And there are striking similarities in how aid and business work. Aid contracts are awarded by competitive tender. Aid agencies are run like corporations, headed by chief executives whose subordinates run departments such as marketing and human re sources. And aid workers, like their corporate counterparts, plot long careers stretching from the regions in this case African villages to the top of the ladder at headquarters, perhaps a U.N.-agency office in New York City. For this, they are generously rewarded. Add up the tax-free (except for U.S. citizens) salary of $139,074 to $204,391 earned by a midranking U.N. manager in, say, eastern Congo. Toss in his $75,000 car, his business-class flights home and to development conferences around the world, his children's education and tens of thousands of dollars a year in other expenses and the total comes to about half a million dollars a year.
Big aid agencies are especially like big businesses. In theory, the goal of every aid agency should be to close up shop, its job done. In practice, that's often still true of smaller, volunteer projects. But larger agencies focus not on folding but on expanding. The core proposition of global aid conglomerates like Oxfam or Save the Children or CARE or World Vision is not expert, specialized assistance but a branded, indiscriminate offer of help. In one country, that help might involve digging wells; in another, running a school; in a third, distributing medicine; in a fourth, advising on microfinance. Expertise in a particular disease or disaster or country or type of aid is often something acquired on the job.